Thermal assessment statement for a detached house

GENERAL INFORMATIONS

Auditor general

information

Name

First name

Date of visit Statement No.

General customer

information

Name

First name

Phone Number

E-mail address

Number of people

in the hearth

Tax income

Address

Construction date

Altitude

m

Occupancy of

accommodation

☐ for over a year ☐ for less than a year

Comfort level

winter☐ bad

☐ OK ☐ Good

summer☐ bad

☐ OK

☐ Good

Client goals

☐ Improve thermal comfort ☐

Beautify housing

☐ Save money

☐ Increase the value of the property

☐ Adapt / rearrange the accommodation ☐

Reduce the environmental footprint ☐ Solve a

breakdown / deterioration

Recommendations

(to be completed at

end of visit)

Change of heating mode ☐ CAP A/

E ☐ CAP A/A

☐ Pellet boiler

☐ Other:

Gesture of isolation

☐ ITE/ ☐ ITI

m²

☐ Low floor

m²

☐ Lost attics

☐ Crawlers

m²

DHW mode change ☐

Thermodynamic balloon

I

☐ Individual solar water heater

I

Installation of a ventilation system

☐ CMV Hygro B ☐ CMV Hygro A

Comments:

Translated from French to English - www.onlinedoctranslator.com

High floor configuration

Floor type

high

☐ Lost attics ☐ Converted attic ☐ Terrace roof

Big work

☐ Wood ☐ Concrete or earth

☐ Ceiling ☐ I don't know

Insulation

☐ None ☐ > 10 years ☐ 5 to 10 years ☐ <5 years

Insulation thickness

cm

☐ I don't know

If convertible attic

inform

Surface of crawlers

m²

Exterior ceiling surface

m²

If attic lost

to inform

Attic area

lost

m²

☐ Unrolled insulation ☐ Blown Insulation

Pphoto

HIGH FLOOR PHOTO

Comments

Configuration of exterior walls

NORTH FACADE

Composition of the exterior wall

Big work

Rock

Concrete

☐ Masonry local stones

☐ Concrete block

☐ Grindstones

☐ Bottom ash concrete

☐ Hollow Brick

☐ Other:

☐ Formed concrete

☐ Aerated concrete

Brick

☐ Solid brick

☐ Honeycomb brick

Earth

Drink

☐ Rammed earth

☐ Plank

☐ Cob / Wood pan

☐ Timber frame

wall thickness

cm

☐ I don't know

☐ 5 to 10 years

Insulation

☐ None ☐ > 10 years

☐ <5 years

☐ I don't know

Thickness

insulating

cm

☐ I don't know

Orientation of the

facade

☐ NE ☐N ☐ NO

Dimensions of the wall

outside

Height

mLength

m

Surface

m²Adjoining area

m²

If presence of sub-facades, or if non-

rectangular facade, fill in

Area 2 Area 3 Area 4

☐ Sprocket

Total surface of the

facade

m²

Area to be insulated

m²

☐ ITE/☐ ITI

Pphoto

Census of openings

Kind

opening

No. L(m) H(m) Frame Glazing Shutter

Pphoto

Comments

Fenêtre

Bois

Fenêtre

PVC

Aucun

Configuration of exterior walls

EAST FACADE

Composition of the exterior wall

Big work

Rock

Concrete

☐ Masonry local stones

☐ Concrete block

☐ Grindstones

☐ Bottom ash concrete

☐ Hollow Brick

☐ Other:

☐ Formed concrete

☐ Honeycomb brick

☐ Aerated concrete

Brick

☐ Solid brick

Earth

Drink

☐ Rammed earth

☐ Plank

☐ Cob / Wood pan

☐ Timber frame

wall thickness

cm

☐ I don't know

☐ 5 to 10 years

Insulation

☐ None ☐ > 10 years

☐ <5 years

☐ I don't know

Thickness

insulating

cm

☐ I don't know

Orientation of the

facade

☐ NE ☐E

☐ ES

Dimensions of the wall

outside

Height

m

Length

m

Surface

m²

Adjoining area

m²

If presence of sub-facades, or if non-

rectangular facade, fill in

Area 2 Area 3 Area 4

☐ Sprocket

Total surface of the

facade

m²

Area to be insulated

m²

☐ ITE/☐ ITI

Pphoto

Census of openings

Kind

opening

No. L(m) H(m) Frame Glazing Shutter

Pphoto

Comments

Fenêtre

Aucun

Fenêtre

Aucun

Configuration of exterior walls

SOUTH FACADE

Composition of the exterior wall

Big work

Rock

Concrete

☐ Masonry local stones

☐ Concrete block

☐ Grindstones

☐ Bottom ash concrete

☐ Hollow Brick

☐ Other:

☐ Formed concrete

☐ Honeycomb brick

☐ Aerated concrete

Brick

☐ Solid brick

Earth

Drink

☐ Rammed earth

☐ Plank

☐ Cob / Wood pan

☐ Timber frame

wall thickness

cm

☐ I don't know

☐ 5 to 10 years

Insulation

☐ None ☐ > 10 years

☐ <5 years

☐ I don't know

Thickness

insulating

cm

☐ I don't know

Orientation of the

facade

☐ N/A ☐S

☐ ES

Dimensions of the wall

outside

Height

m

Length

m

Surface

m²

Adjoining area

m²

If presence of sub-facades, or if non-

rectangular facade, fill in

Area 2 Area 3 Area 4

☐ Sprocket

Total area of

the facade

m²

Area to be insulated

m²

☐ ITE/☐ ITI

Pphoto

Census of openings

Kind

opening

No. L(m) H(m) Frame Glazing Shutter

Pphoto

Comments

Fenêtre

Aucun

Fenêtre

Aucun

Configuration of exterior walls

WEST FACADE

Composition of the exterior wall

Big work

Rock

Concrete

☐ Masonry local stones

☐ Concrete block

☐ Grindstones

☐ Bottom ash concrete

☐ Hollow Brick

☐ Other:

☐ Formed concrete

☐ Honeycomb brick

☐ Aerated concrete

Brick

☐ Solid brick

Earth

Drink

☐ Rammed earth

☐ Plank

☐ Cob / Wood pan

☐ Timber frame

wall thickness

cm

☐ I don't know

☐ 5 to 10 years

Insulation

☐ None ☐ > 10 years

☐ <5 years

☐ I don't know

Thickness

insulating

cm

☐ I don't know

Orientation of the

facade

☐ N/A ☐Y

☐ NO

Dimensions of the wall

outside

Height

m

Length

m

Surface

m²

Adjoining area

m²

If presence of sub-facades, or if non-

rectangular facade, fill in

Area 2 Area 3 Area 4

☐ Sprocket

Total surface of the

facade

m²

Area to be insulated

m²

☐ ITE/☐ ITI

Pphoto

Census of openings

Kind

opening

No. L(m) H(m) Frame Glazing Shutter

Pphoto

Comments

Porte

Bois

Fenêtre

Aucun

Double vitrage ancien (>10 ans)

Volets battants PVC

Aucun

ARCHITECTURE - DESCRIPTION OF THE BUILDING

General configuration of the house

Living space Unheated surface Ceiling height

Basement

Ground floor

1erstage

2nd Floor

3rd floor

Living space

total

Burial of sub-

floor

☐ Unburied

☐ Buried

☐ Semi-buried

m²

Housing shape

☐ Compact ☐ Elongated ☐ L-shaped

☐ U-shaped

☐ Other:

Low floor configuration

Low floor type

☐ On basement

☐ Crawl space ☐ On land

Fat-

work

☐ Wood

☐ Concrete or earth

☐ Brick

☐ I don't know

Insulation

☐ None

☐ > 10 years

☐ 5 to 10 years

☐ <5 years

☐ I don't know

Insulation thickness

cm

Bottom floor area

m²

Area to be insulated

m²

Picture

LOW FLOOR PHOTO

Comments

VENTILATION

Ventilation system

☐ By infiltration ☐ High grids

and bass

☐ Simple CMV

Auto Flow

☐ VMC Double

Flow

☐ CMV Hygro A

☐CMV Hygro B

Number of pieces

Number of bathrooms

HEATING SYSTEM and DHW

Energy

☐ Fuel oil ☐Gas ☐Propane ☐Wood ☐ Electricity

☐ Coal

Generator

☐ High T° boiler ☐ Electric

convectors

☐ Low T° boiler

☐ Wood stove ☐ Insert

☐ Condensing boiler

☐ Fireplace

of

heating

Year Rated p.

Yield p.

nominal

Placed in a heated volume

Characteristic

s

☐Yes ☐ No

Picture

Emission system

☐ Cast iron radiator ☐ Steel radiator ☐ Fan coil

☐ Underfloor heating ☐ Other:

Heated area

by the show

☐ Cast iron radiator ☐ Steel radiator ☐ Fan coil

☐ Heated floor ☐ Other:

Heated area

by the show

☐ Cast iron radiator ☐ Steel radiator ☐ Fan coil

☐ Heated floor ☐ Other:

Heated area

by the show

Pphoto

Comments

DHW production

☐ Instant

☐ Generator

heating

☐ Gas water heater

☐ Other:

☐ Accumulation

☐ Generator

heating

☐ Gas water heater

☐ Water heater

electric

☐ Balloon

thermodynamics

☐ Other:

Volume

ECS seniority

Placed in a heated volume

Pphoto

☐Yes ☐ No

Electric meter

☐ Single phase ☐ Three-phase

meter power

Pphoto

< 5 ans

18 kVA